I, ___________________________________, authorize and consent to the treatment for the removal of superficial wrinkles and/or pigmented lesions with the Phoenix-15 CO2 Laser.

I have been advised by, _____________________________________________ of _________________________________________ of the purported advantages and disadvantages associated with this treatment.

I understand that treatment with this laser system varies from patient to patient and that that more that 1-treatment may be required.

Although rare, adverse outcomes such as hyperpigmentation and/or hypopigmentation (darkening or lightening of the skin), skin texture changes, and scarring can occur. _________ (Initials)

No guarantees have been made to me regarding the outcome of the treatment or any improvements in my condition due to the procedure._________ (initials)

I understand that the possible benefits are the reduction and the elimination of wrinkles and pigmented lesions. _________ (initials)

Due to the brilliance of the laser light energy used, I agree to wear eye protection to shield my eyes. ________ (initials)

I have been given the opportunity to ask questions and have received satisfactory answers to those questions. ________ (initials)

I hereby authorize the taking of photographs. These photographs may be used to demonstrate the results this laser produces. ________ (initials)

I hereby indemnify and hold harmless Rohrer Aesthetics,Inc., the treating technician and ____________________________________ from any and all liability, damages, cost and expenses arising from or out of the use Phoenix-15 CO2 Laser for treatment of wrinkles and/or the removal of pigmented lesions. _______

(initials)

With all of the above information understood, I am choosing to be treated with the Phoenix-15 CO2 Laser.

__________________________________ Signature

____________________________________ Print Name

____________________________________ Date